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Use of Chaperones Policy

1. Purpose

The purpose of this policy is to ensure that the use of chaperones within {{org_field_name}} is managed in a manner that protects the dignity, safety, and rights of all individuals during personal care, medical examinations, treatments, or sensitive conversations. This policy supports compliance with the Regulation and Inspection of Social Care (Wales) Act 2016, the Social Services and Well-being (Wales) Act 2014, the Equality Act 2010, and Care Inspectorate Wales (CIW) expectations around safe care, safeguarding, and respect for privacy and choice. The use of chaperones is an essential safeguarding measure that also reassures service users and supports transparency and accountability among staff.

2. Scope

This policy applies to all staff at {{org_field_name}}, including care workers, nurses, health professionals, agency staff, and any visiting medical personnel. It applies to all residents receiving care or support where the use of a chaperone may be appropriate, particularly during personal, intimate, or potentially distressing procedures or examinations. It also includes instances of communication involving sensitive personal issues, complaints of abuse, or where there is a risk of misinterpretation or discomfort.

3. Related Policies

This policy should be read in conjunction with the following:
CHW07 – Person-Centred Care Policy
CHW08 – Dignity and Respect Policy
CHW09 – Consent to Care Policy
CHW11 – Safe Care and Treatment Policy
CHW13 – Safeguarding Adults from Abuse and Improper Treatment Policy
CHW16 – Health and Safety at Work Policy
CHW18 – Risk Management and Assessment Policy
CHW27 – Staff Supervision, Training, and Development Policy
CHW30 – Equality, Diversity, and Inclusion Policy
CHW40 – Assisting with Personal Care Policy

4. Policy Statement and Implementation

4.1 Definition and Role of a Chaperone

A chaperone is a suitably trained and competent individual who is present during personal, intimate or clinical interactions to provide support, reassurance and appropriate safeguarding for the resident receiving care, treatment or examination.

The role of a chaperone is to:

• provide appropriate emotional reassurance and support to the resident;
• help protect the resident’s privacy, dignity, safety and rights;
• act as an impartial observer of the interaction where appropriate;
• help reduce the risk of misunderstanding or misinterpretation;
• recognise and respond appropriately to any signs of distress, discomfort, abuse, neglect or improper treatment; and
• support transparency and professional accountability.

A chaperone may be another appropriately trained member of staff. Where reasonably practicable, the resident’s preferences regarding the person acting as chaperone, including any preference relating to sex, gender, culture, religion or previous experiences of care, must be considered and respected.

The presence of a chaperone does not remove or reduce the responsibilities of the member of staff or healthcare professional providing the care, treatment or examination.

A chaperone must not be used as a substitute for appropriate staffing levels, safe working arrangements, professional supervision or compliance with safeguarding procedures.

4.2 When a Chaperone Should Be Offered

A chaperone should be offered where this is appropriate to the circumstances, taking account of the nature of the care, examination or interaction and the resident’s wishes, preferences, needs and assessed risks.

Circumstances in which a chaperone should be considered or offered include:

• during intimate examinations or procedures;
• during personal or intimate care where the resident requests another person to be present;
• during physical examinations conducted by visiting healthcare professionals, where appropriate;
• where the resident is anxious, distressed or has experienced previous trauma or abuse and the presence of another person may provide reassurance;
• where a resident specifically requests a chaperone;
• where an individual assessment identifies a safeguarding or other significant risk which may be reduced by the presence of a chaperone;
• during sensitive discussions or interactions where the resident requests support from another person; and
• where a healthcare professional, acting within their professional responsibilities, considers that a chaperone should be offered.

The decision to offer or use a chaperone must be person-centred and proportionate. The presence of a chaperone must not be imposed as a routine requirement where this would unnecessarily interfere with the resident’s privacy, dignity, autonomy or preferences.

A resident who has capacity to make the relevant decision has the right to accept or decline a chaperone. Refusal must not, by itself, be treated as a safeguarding concern or as a reason to deny necessary care.

Where there are particular risks associated with proceeding without a chaperone, staff must consider these risks individually and identify appropriate arrangements in consultation with the resident and, where relevant, the healthcare professional responsible for the examination or treatment.

4.3 Consent, Capacity and Communication

Before any procedure, examination, personal care intervention or other interaction for which a chaperone is being considered begins, the resident must be given appropriate information about the proposed care, examination or intervention and about the purpose and role of the chaperone.

Information must be provided in a way that the resident can understand, taking account of their:

• preferred language;
• communication needs;
• sensory impairment;
• cognitive needs;
• level of understanding; and
• requirement for communication aids, interpretation or other support.

Consent to the care, examination or intervention and consent to the presence of a chaperone must be considered separately.

A resident who has capacity to make the relevant decision has the right to accept or decline a chaperone and may change their mind or withdraw their consent at any time. Staff must respect that decision unless there is a separate lawful reason why the proposed care or examination cannot safely or appropriately proceed.

Where there is reason to doubt a resident’s capacity to make the particular decision, staff must act in accordance with the Mental Capacity Act 2005 and CHW39 – Mental Capacity and Deprivation of Liberty Safeguards Policy.

Capacity must be assessed in relation to the specific decision that needs to be made and at the time the decision is required.

A resident must not be treated as lacking capacity solely because of:

• their age;
• a diagnosis or disability;
• their appearance;
• their behaviour;
• communication difficulties; or
• the fact that they make a decision that others consider unwise.

Before concluding that a resident lacks capacity, all practicable steps must be taken to support them to make the decision themselves. This may include:

• providing information in an accessible format;
• using the resident’s preferred method of communication;
• allowing additional time;
• choosing an appropriate time and environment;
• using communication aids or interpreters where required; and
• involving a person who understands the resident’s communication needs, where appropriate and lawful.

Where the resident lacks capacity to make the relevant decision, staff must establish whether there is any person with lawful authority to make the decision, such as an attorney acting under a valid and applicable Lasting Power of Attorney for health and welfare or a court-appointed deputy with relevant authority.

Where no authorised person can make the decision, any decision about proceeding with care, treatment or the presence of another person must be made in accordance with the Mental Capacity Act 2005 best-interests requirements.

The decision must take account of:

• the resident’s past and present wishes and feelings;
• the resident’s beliefs and values;
• the views of relevant persons where it is appropriate and lawful to consult them;
• the risks and benefits of the available options; and
• whether the purpose can be achieved in a less restrictive way.

Any capacity assessment, best-interests decision and the reasons for the decision must be appropriately recorded.

Nothing in this policy permits treatment, examination, personal care, restraint or a restriction of liberty without the consent or other lawful authority required for that intervention.

4.4 Chaperone Training and Responsibilities

A member of staff acting as a formal chaperone on behalf of {{org_field_name}} must have received instruction or training appropriate to the role and must understand their responsibilities concerning:

• privacy, dignity and respect;
• confidentiality and information governance;
• professional boundaries;
• consent and mental capacity;
• safeguarding and the reporting of concerns;
• recognising signs of distress, discomfort, abuse, neglect or improper treatment; and
• accurate record keeping.

The chaperone’s role is to provide appropriate support and reassurance, observe the interaction where necessary and help safeguard the resident’s dignity, safety and rights.

The chaperone must maintain professional boundaries and must not unnecessarily participate in, interrupt or observe aspects of care that are not relevant to their role.

The chaperone may remain present for the period for which their presence has been agreed. The resident’s consent to the chaperone’s presence remains relevant throughout the interaction.

If a resident who has capacity:

• asks the chaperone to leave;
• withdraws consent to their presence; or
• indicates through words, behaviour or other communication that they no longer consent,

this must be respected.

The member of staff or healthcare professional responsible for the care or examination must then determine whether it remains lawful, appropriate and safe to continue.

Where the resident lacks capacity, the continued presence of a chaperone must be consistent with any relevant best-interests decision and must not impose an unnecessary or disproportionate intrusion on the resident’s privacy.

A chaperone must not undertake clinical, nursing or care tasks solely because they are acting as the chaperone. They may undertake another task only where:

• this is within their normal role;
• they are appropriately trained and competent;
• they are authorised to undertake the task; and
• doing so does not prevent them from fulfilling the purpose for which their presence as a chaperone was required.

Any concern arising during the interaction must be acted upon immediately in accordance with the resident’s safety needs, this policy, CHW13 – Safeguarding Adults from Abuse and Improper Treatment Policy and any other relevant procedure.

The chaperone’s presence and any significant event, concern or action arising from the interaction must be recorded accurately in the resident’s care record.

4.5 Gender, Cultural, Religious and Individual Preferences

{{org_field_name}} respects the cultural, religious, sex, gender and other individual preferences of residents in relation to who is present during personal care, intimate care, examinations or treatment.

Where reasonably practicable, arrangements must take account of the resident’s preferences regarding the person acting as chaperone, including where the resident expresses a preference for a chaperone of a particular sex or gender.

Staff must also be sensitive to:

• the resident’s gender identity;
• cultural and religious beliefs;
• previous experiences of trauma or abuse;
• communication needs;
• cognitive impairment;
• sensory impairment;
• learning disabilities; and
• any other characteristic or circumstance relevant to the resident’s dignity, privacy and well-being.

Where a resident’s stated preference cannot reasonably be accommodated, staff must explain this sensitively and consider whether an acceptable alternative arrangement is available.

Any decision must avoid unlawful discrimination and must be consistent with the Equality Act 2010, the resident’s assessed needs, their personal plan and the service’s responsibility to provide safe and respectful care.

4.6 Safeguarding and Protection

The use of a chaperone may form part of the service’s safeguarding arrangements, but the presence of a chaperone does not replace the duty of all staff to remain alert to abuse, neglect, improper treatment, unlawful restraint, exploitation or any other safeguarding concern.

If a chaperone or any other person observes, receives information about or reasonably suspects abuse, neglect or improper treatment, they must take immediate action in accordance with CHW13 – Safeguarding Adults from Abuse and Improper Treatment Policy and the Wales Safeguarding Procedures.

Immediate action must include, as appropriate:

• taking reasonable steps to secure the immediate safety and well-being of the resident and any other person who may be at risk;
• obtaining urgent medical assistance or contacting the emergency services where necessary;
• preserving relevant information or evidence where appropriate;
• reporting the concern immediately to the Registered Manager, safeguarding lead or other designated senior person;
• making or facilitating the appropriate safeguarding referral to the relevant local authority or other statutory agency without avoidable delay; and
• ensuring that the concern, allegation, observations, actions taken, referrals made and outcomes known to the service are accurately recorded.

Where the concern relates to the conduct of a member of staff, volunteer, agency worker or other person working at the service, appropriate action must also be taken under the service’s:

• safeguarding procedures;
• disciplinary procedures;
• whistleblowing procedures;
• staff fitness procedures; and
• regulatory notification procedures.

This includes consideration of referrals or notifications to the Disclosure and Barring Service, Social Care Wales, another professional regulator, the police and Care Inspectorate Wales where the applicable legal threshold is met.

A resident who has capacity is entitled to decline the presence of a chaperone. A resident’s refusal of a chaperone, including repeated refusal, must not in itself be treated as evidence of abuse, neglect, improper treatment or a safeguarding concern.

Staff must nevertheless act where there are separate facts, observations, disclosures or circumstances giving rise to a safeguarding concern.

Where there is disagreement about whether an interaction should proceed without a chaperone, the matter must be considered on an individual basis, taking account of:

• the resident’s wishes and preferences;
• the resident’s capacity in relation to the relevant decision;
• the resident’s personal plan;
• any identified risks;
• the nature and urgency of the proposed care or examination; and
• the professional responsibilities of the person undertaking the care, treatment or examination.

4.7 Recording and Documentation

Records relating to the offer, acceptance, refusal or use of a chaperone must be accurate, factual, contemporaneous and sufficiently detailed to demonstrate how the resident’s wishes, rights, safety and well-being were considered.

Where a chaperone is offered or used, the resident’s care record must include, as applicable:

• the date and nature of the care, examination, procedure or interaction;
• whether a chaperone was offered;
• whether the resident accepted or declined the chaperone;
• the name and role of the chaperone where one was present;
• any relevant preference expressed by the resident about the person acting as chaperone;
• any reasonable steps taken to meet the resident’s communication, cultural, religious, sex, gender or other relevant needs or preferences;
• any withdrawal of consent to the chaperone’s presence during the interaction;
• any significant expression of distress, objection or discomfort;
• where capacity was in doubt, the outcome of the relevant decision-specific capacity assessment;
• where the resident lacked capacity, details of the lawful decision-making process, including any relevant attorney, deputy or best-interests decision;
• any reason why an interaction did not proceed, was interrupted or was rearranged;
• any safeguarding concern, allegation or significant observation arising from the interaction; and
• any action, escalation, referral or notification made as a result.

Entries must distinguish clearly between:

• factual observations;
• information reported by another person; and
• professional judgement.

Records must not contain unnecessary, judgemental or speculative statements.

Where a safeguarding concern or allegation arises, the record must include:

• the substance of the concern or allegation;
• immediate protective action taken;
• persons informed;
• referrals made;
• regulatory notifications made where applicable; and
• any other action required under the service’s safeguarding procedures.

Records must be completed as soon as practicable following the event and must be maintained securely in accordance with the service’s records-management arrangements, applicable data-protection requirements and Regulation 59 of the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended.

Records must be retained for the period required by the applicable legislation and the service’s records-retention arrangements.

4.8 Managing Declined or Withdrawn Chaperone Consent

Where a resident who has capacity declines a chaperone, their decision must normally be respected.

Staff must not pressure, coerce or disadvantage a resident because they have chosen not to have a chaperone present.

The refusal must be recorded together with any relevant discussion about the resident’s wishes and the arrangements for proceeding.

Refusal of a chaperone does not, by itself, authorise staff to withhold necessary care or support.

Essential, urgent or time-critical care must not be unnecessarily delayed solely because the resident has declined a chaperone. Staff must consider how the resident’s assessed needs can be met safely, lawfully and in a manner that respects their privacy, dignity and autonomy.

Where there is an identified risk associated with proceeding without a chaperone, staff must undertake an individual and proportionate assessment of the circumstances.

Alternative arrangements should be considered where appropriate, which may include:

• offering another suitable member of staff;
• taking account of the resident’s preference concerning who is present;
• changing the staff member undertaking the care where practicable;
• altering the timing or setting where this does not adversely affect the resident;
• seeking advice from the Registered Manager or senior person; or
• in the case of a clinical examination or treatment, discussing the matter with the healthcare professional responsible for that intervention.

A non-urgent examination, procedure or interaction may be rearranged where the person responsible for undertaking it determines that it cannot appropriately or safely proceed without a chaperone.

The reason for the decision and the alternative arrangements must be explained sensitively to the resident and recorded.

Where care or treatment is urgent, the priority must be the resident’s immediate health, safety and well-being. Any decision to proceed without a chaperone must take account of:

• consent;
• capacity;
• necessity;
• proportionality;
• assessed risk; and
• any relevant professional requirements.

The decision must be documented.

Where the resident lacks capacity to decide whether a chaperone should be present, staff must follow the decision-making requirements set out in section 4.3 of this policy and the Mental Capacity Act 2005.

Refusal, resistance or distress must not be disregarded merely because the resident has been assessed as lacking capacity.

4.9 Multi-Agency Working and Visiting Professionals

Where visiting healthcare or other professionals attend {{org_field_name}} to undertake an examination, assessment, treatment or other sensitive interaction, staff must support the resident to understand what is proposed and, where appropriate, that they may request a chaperone.

Visiting professionals may include, but are not limited to:

• GPs;
• district or community nurses;
• physiotherapists;
• occupational therapists;
• dentists;
• podiatrists;
• mental health professionals; and
• other health or social care professionals.

Where a resident requests a chaperone, a suitably trained and competent member of the care home team may act as the chaperone where this is appropriate and agreed.

Where the visiting professional has their own chaperone arrangements or is required to follow professional guidance concerning chaperones, the care home must cooperate with those arrangements where they are consistent with the resident’s rights, wishes, consent and safety.

The visiting professional remains responsible for complying with the requirements of their own employer, professional regulator and professional standards.

Care home staff must not assume responsibility for making a clinical decision that properly rests with the visiting healthcare professional.

Where there is a disagreement or concern about whether an examination or treatment should proceed, the resident’s immediate safety and well-being must be prioritised and the matter escalated appropriately.

All relevant visits, examinations, treatments and chaperone arrangements must be recorded in accordance with the resident’s care-record requirements.

4.10 Audit, Monitoring and Continuous Improvement

The Registered Manager is responsible for ensuring that the operation of this policy is monitored as part of the service’s governance and quality-assurance arrangements.

Monitoring may include review of:

• care records involving the use, offer or refusal of chaperones;
• safeguarding concerns arising during personal, intimate or clinical interactions;
• incidents and complaints;
• staff understanding and application of the policy;
• relevant training and competency records;
• feedback from residents and their representatives, where appropriate; and
• any identified patterns, themes or recurring concerns.

Where monitoring identifies a risk to residents, a failure to comply with legal or regulatory requirements, or a deficiency in staff practice, appropriate remedial action must be taken without avoidable delay.

Actions may include:

• review of the resident’s personal plan or risk assessment;
• additional staff supervision;
• further training or competency assessment;
• revision of procedures;
• safeguarding action;
• disciplinary action where appropriate; or
• referral or notification to external bodies where required.

Information arising from monitoring must contribute, where relevant, to the service’s arrangements for monitoring, reviewing and improving the quality of care and support.

Any lessons arising from incidents, complaints, safeguarding concerns or regulatory findings must be communicated appropriately and used to improve practice.

4.11 Notifications and External Reporting

Safeguarding referrals and internal incident reporting do not replace any separate statutory duty to notify Care Inspectorate Wales or another regulatory or statutory body.

The Registered Manager and Responsible Individual must ensure that incidents arising in connection with the use, absence or conduct of a chaperone are considered against the notification requirements contained in the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended.

Where the applicable notification criteria are met, Care Inspectorate Wales must be notified in accordance with the Regulations and current CIW notification arrangements.

This includes, where applicable:

• abuse or an allegation of abuse in relation to an individual involving the service provider, a member of staff or a volunteer;
• an allegation of misconduct by a member of staff;
• a serious accident or injury;
• an incident reported to the police; and
• any other event for which notification is required by the Regulations.

Notifications to Care Inspectorate Wales must be made within the timescale and by the method required by the applicable Regulations and current CIW arrangements.

Where required, the notification must be submitted through CIW Online or any replacement notification system specified by Care Inspectorate Wales.

Where a safeguarding concern is identified, the service must also make any necessary referral to the relevant local authority safeguarding service in accordance with the Wales Safeguarding Procedures.

A notification to Care Inspectorate Wales does not replace a safeguarding referral, and a safeguarding referral does not replace a required notification to Care Inspectorate Wales.

Where the circumstances indicate that a criminal offence may have occurred or there is an immediate risk of significant harm, the police must be contacted as appropriate.

Where the conduct of a worker raises concerns about their suitability to work with adults at risk, the Registered Manager and Responsible Individual must consider and make any mandatory referral or notification to:

• the Disclosure and Barring Service;
• Social Care Wales;
• the Nursing and Midwifery Council or another relevant professional regulator, where applicable; and
• any other body to which a statutory referral is required.

All referrals and notifications must be appropriately recorded, including:

• the date of the referral or notification;
• the organisation or person notified;
• the reason for the referral or notification;
• the person who made it;
• any reference number received; and
• any response or further action required.

Records of referrals and notifications must be retained securely in accordance with the service’s records-management arrangements.

5. Policy Review

This policy will be reviewed annually or earlier in response to changes in legislation, guidance from CIW, or following any incident involving the inappropriate use or absence of a chaperone. The Registered Manager is responsible for ensuring staff awareness and adherence to this policy and for integrating it into ongoing safeguarding and care practice training.

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Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
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